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NavMed 369 




UNITED STATES NAVY 




Editor - Captain L. B. Marshall, MC, USN <RET) 



Vol. 27 



Friday, 23 March 1956 



No. 6 



TABLE OF CONTENTS 



Penicillin Prophylaxis of Gonorrhea 

Biological-Medical Considerations in Atomic Defense 

Thoracic Pain in Cardiovascular Disease 

Artificial Pneumoperitoneum 

The Nonhospitalized Tuberculosis Patient 

Acerola Juice 

Lumbar and Sacral Compression Radiculitis 

Gastric Polyps and Adenomas 

Thromboembolic Disease in Obstetrics and Gynecology 

Notice to All Military Service Members of the A. M. A 

Reunion at National Naval Medical Center 

Admiral Burke Heads Navy Mutual Aid Association 

From the Note Book 

Professional Care of Patients {BuMed Notice 6320) 

Short Postgraduate Courses for Medical Officers {BuMed Inst. 1520.8) 

Emergency Aspirator for Ambulances (BuMed Notice 6700) 

Defective Medical and Dental Material (BuMed Inst. 6710. 27) 

Precautions Concerning Water for Injection (BuMed Notice 6710) . . . . 

Antibiotics, Exten sion of Potency Dates (BiiMed Notice 6710) • • 

Ungraded Position Ratings (BuMed Inst. 12250. lA) 

Nonstatic Blankets (BuMed Inst. 5101.2) 

DENTAL SECTION 
Dental Records in Plane Crashes 28 Ensigns fl995) from Class '59 

Reserve Dental Companies 29 Medico-Dental Symposium . . 

Professional Books. . 29 Dental Clinic in Philadelphia 

MEDICAL RESERVE SECTION 
Application Forms for Courses. . 30 Special Clinical Services. . . . 
New England Hospital Assembly Approved for Point Credits , . 
PREVENTIVE MEDICINE SECTION 



Industrial Hearing Conservation, . 33 
Foodborne Disease Outbreaks .... 34 
TPI Test in the Navy 35 



Occupational Medicine 

Preventive Medicine Manual. 
Industrial Health in England . 



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Medical News Letter, Vol. 27, No. 6 



Policy 

The U. S. Navy Medical News Letter is basically an official Medical 
Department publication inviting the attention of officers of the Medical 
Department of the Regular Navy and Naval Reserve to timely up-to-date 
items of official and professional interest relative to medicine, dentistry, 
and allied sciences. The amount of information used is only that necessary 
to inform adequately officers of the Medical Department of the existence 
and source of such information. The items used are neither intended to be 
nor susceptible to use by any officer as a substitute for any item or article 
in its original form. Ail readers of the News Letter are urged to obtain 
the original of those items of particular interest to the individual. 

jjc jj; ){C 5{c 3^ 

Notic e 



Due to the critical shortage of medical officers, the Chief, Bureau 
of Medicine and Surgery, has recommended, and the Chief of Naval Person- 
nel has concurred, that Reserve Medical officers now on active duty who 
desire to submit requests for extension of active duty at their present sta- 
tions for a period of three months or more will be given favorable consid- 
eration. BuPers Instruction 1926. IB applies. 

Penicillin Prophylaxis of Gonorrhea 



BuMedlnst 6222. 3B of 25 October 1954 has been interpreted by many 
as prohibiting the use of oral penicillin for the prevention of gonorrhea. 
This interpretation is incorrect. Medical officers are at liberty to use 
this chemoprophylaxis as they desire and should not refuse it to those who 
request it only on the basis of this instruction. 

For the reasons set forth in that instruction, major emphasis on 
the prevention of venereal diseases should not be focused on chemopro- 
phylaxis, since oral penicillin has been shown to be effective only in the 
prevention of gonorrhea, whereas the real Medical Department problem 
is bound up with other venereal diseases. 

****** 

The printing of this publication has been approved by the Director 
of the Bureau of the Budget, 16 May 1955. 



Medical News Letter, Vol. 27, No. 6 
Biol ogical -Medical Considerations in Atomic Defense 



3 



Atomic radiations, whether they arise from nuclear weapons, from 
radioisotopes or radium, or from radiation -producing machines, share 
one distinctive property: During the process of absorption in the body, 
they all interact with tissue by splitting atoms and molecules into pairs 
of electrically charged fragments called ions. 

The remarkable effectiveness of atomic radiations in causing biolog- 
ical injury stems from their property of acting directly on the individual 
atoms and molecules composing tissue. By their ionizing effect, radiations 
may eject electrons from atoms, break up. chemical compounds, displace 
atoms in organized molecules, generate toxic substances and, in general, 
cause important changes in the submicroscopic structure of body cells. 

The specific injury produced by radiation in any given circumstance 
probably depends on many variable factors, such as the density of ioniza- 
tion, the kind of tissue irradiated, and the kind or location of the molecules 
affected. Observed injuries include the mutation of genes, inactivation of 
enzymes, inhibition of cell division, and fatal disturbance of tissue functions. 

So far as it known, there are four possible results of exposing a living 
cell to radiation. The cell may be killed. It may be crippled transiently or 
permanently, or it may merely have nonessential molecules ionized and, 
therefore, actually not be harmed at all by the radiation. Symptoms of 
radiation injury (skin erythema, radiation sickness, decreased fertility) 
appear in an individual only after a sufficient number of cells have been 
injured or killed. Unless the exposure has been sufficient to cause skin 
erythema, there may be no immediate external warning that a sublethal 
or even a minimum lethal dose of radiation has been received. Some 
changes appear early. Others may be seen only after prolonged periods 
of latency. Evidence of injury from minimal doses of radiation may not 
show up for months or even years. 

The recognizable changes produced in cells by radiation are of many 
sorts. They include changes in permeability of the cell membrane, changes 
in the staining characteristics of cells, changes in viscosity of the proto- 
plasm, changes in chromosomes, swelling of cellular components, pro- 
duction of abnormal cell divisions, distortion of cell structure, and many 
more obscure but measurable changes. 

Each of the human body's many different tissues responds differently 
to radiation exposure. The responses, in general, are a summation of the 
responses of the various cells and cell types composing the specific tissue. 

Rapidly growing or metabolizing tissues are usually more sensitive 
to radiation than are quiescent tissues. Lymphocytic tissues (lymph nodes, 
tonsils) are more easily affected than are muscle or nerve tissues. Tissue 
cells in an organ are more easily injured by radiation than tissue cells 
grown in a culture. 



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Medical News Letter, Vol. 27, No. 6 



Tissues so differ in reaction to radiation absorption that it is possible 
to classify them in a loose fashion according to the doses of radiation they 
will successfully withstand. The following list is based on the available 
data and represents the approximate response of tissues exposed to divided 
doses of roentgen rays generated at 200 kilovolts: 

Highly radiosensitive (cells seriously injured or killed by doses of 

600 roentgens or less): lymphocytes; bone marrow cells; sexual 

cells (testical and ovary). 

Moderately radiosensitive (cells seriously injured or killed by doses 
of 600 to 3000 roentgens): salivary glands; epithelium of skin; endo- 
thelium lining blood ves sels ;■ bone (growing); epithelium of stomach 
and intestine; connective tissue; elastic tissue. 

Radioresistant (cells show little damage unless dose exceeds 3000 
roentgens): kidney; liver; thyroid, pancreas, pituitary, adrenal, and 
parathyroid glands; bone (mature); cartilage; muscle; brain and other 
nervous tissue. 

Quite recently, the understanding has been that the organ systems 
most fundamentally affected are the central nervous system, the blood 
forming organs, and the gastrointestinal tract. Nerve tissues, for example, 
do not recover from injury as do many other tissues. 

The blood forming organs, the skin, the membranes lining body cav- 
ities, and the secreting glands may regenerate completely and resume their 
normal functions. Muscle, brain, and portions of the kidney and eye cannot 
regenerate; repair of them results only in scar formation. Even those tissues 
that can regenerate may fail to respond after repeated ionization and so cause 
conditions such as nonhealing ulcers or aplastic anemia. Also, repeated 
regeneration may produce cancerous conditions: epitheliomata, fibrosar- 
comata, or leukemia. There are no constant clinical symptoms which can 
be relied upon to warn of latent radiation injury before the late changes 
become manifest. 

Not only is there marked variation in radiation sensitivity of different 
kinds of cells and tissues within an individual; there is also some variation 
in the radiosensitivity of individuals of the same species and even more 
variation among different species. 

Experimental observations of many different species indicate that 
radiations induce an aging and debilitating effect. Each roentgen of exposure 
probably shortens life expectancy of an animal by about one ten thousandth. 
This implies that an exposure rate of 0. 4 milliroentgen equivalent physical 
per day (about what man receives from cosmic and other naturally occurring 
radiation) may shorten the expected life span of a human being by about 4 
weeks if the effect of radiation in man is like that in animals ; or 50 roentgens 
of exposure may shorten the expected human life span by as much as 18 
weeks. Also, radiation exposure induces an increased susceptibility to 
infection. 



Medical News Letter, Vol. 27, No. 6 



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In every discussion of the effects of ionizing radiations, one of 
the first questions put to the physician is, "Will it make me sterile? " 
In response, the physician usually finds it necessary to distinguish be- 
tween potency and fertility. No direct effects on potency have been repor- 
ted. Fertility has been affected. 

Permanent sterilization of the human female requires 400 to 600 
roentgens delivered to the ovary. Sterilization of the human male can be 
produced by 800 to 1000 roentgens delivered to the testes. Either of these 
doses, given as whole -body radiation, would probably be lethal to the ind- 
ividual, and, therefore, danger of causing permanent sterilization by 
single whole -body exposures becomes a theoretical rather than a practical 
question. Reduced fertility and temporary sterility have been induced in 
human beings by single exposures of 200 to 300 roentgens to the gonads 
and in animals by repeated exposures of as little as 1 roentgen per day 
for a number of weeks. 

A few years ago, a survey found that the average number of children 
born to a group of radiologists was 1. 7, whereas the average number of 
children born to a comparable group of physicians not engaged in roentgen- 
ology was 3. Inasmuch as the major difference between the two groups of 
physicians, so far as could be determined, was the practice of roentgenology, 
these data may indicate a reduction in human fertility from repeated exposure 
to relatively small doses of x-rays. 

Genetic or hereditary changes may arise from doses of radiation 
much smaller than those needed to affect fertility. Many genetic experts 
believe that any amount of ionizing radiations may produce hereditary 
changes cumulative throughout the lifetime of the germ plasma line that 
can and will appear in future generations. There is, however, no current 
evidence that radiation workers (x-ray technicians, radiologists, atomic 
workers) who have not abused the maximum permissible dose limits, have 
produced offspring differing from those of the general populace. 

Specifically, from the human genetic studies being made of the com- 
pleted pregnancies among the surviving victims of the atom bombings at 
Hiroshima and Nagasaki, at least one positive finding has been reported. 
The expected normal, male -female ratio has been upset among offspring of 
women exposed within 2000 meters of ground zero {the point immediately 
beneath the exploding bomb) by a statistically significant decrease in male 
births. ■ ■ ^ 

Ionizing radiation can alter the genes in the body (somatic) cells and 
in the reproductive (sexual) cells and so cause them to grow or reproduce 
abnormally. If a gene change occurs in a sexual cell, a mutation will occur 
in later generations, provided that the cell is used in reproduction. If a 
gene change occurs in a cell of growing or regenerating somatic tissue like 
skin, liver, bone, or bone marrow, it may cause cancerous or other harm- 
ful changes in the exposed individual. 



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Medical News Letter, Vol. 27, No. 6 



Among atomic bomb casualties there will be many with multiple 
injuries. Dual or triple modes of injury may be the rule rather than the 
exception. Victims may have burns, traumatic injuries, and radiation 
injuries in any combination. Prognosis in each case will depend on the 
types and extent of the injuries. Those with radiation injuries in addition 
to more orthodox injuries will tend to have a graver prognosis than those 
not having radiation injuries. 

Radiation exposure incurred from the atomic flash is practically 
instantaneous. That from radioactive fallout, because of the rapid decay 
of this material, should be thought of as being suffered within a quite short 
time span: More than 80% of the radiation dose from atomic debris will 
be delivered within 10 hours of the explosion time. The radiologists state 
that radiation exposures delivered over a time span of minutes or hours 
may be thought of as having effects identical to an instantaneous exposure 
of the same roentgen value. On the other hand, exposures incurred over 
a period of days or months have less total biomedical effect on the body as 
a whole than would the same cumulative roentgen dose if it were delivered 
over a period of only hours or minutes. 

There are no known specific agents for the treatment of radiation 
injury. There are no practical prophylactic drugs to temper or avert 
radiation injury consequent to adequate exposure to radiation. Medical re- 
search is continuing in an effort to discover and develop better means of 
diagnosis, prophylaxis, and treatment for the victims of all types of radio- 
logical hazards, including atomic attack. 

The recommended therapeutic measures for radiation sickness and 
its sequelae are almost exclusively symptomatic or supportive in nature. 
They include : 

1. Bed rest plus sedatives to reduce stress demands on the body 
economy. 

Therapy to itnprove nutrition and maintain fluid and mineral balance. 

3. Measures to reduce or prevent infection: antibiotics; aseptic 
techniques in nursing and medical care with emphasis on mouth 
and skin hygiene; leucocytic cream. 

4. Antishock drugs. 

5. Antihistamines (on the theory that shock is precipitated or made 
worse by histamine produced by the radiation -injured tissues), 

6. Antigastric secretants and antinauseants . 

7. Antihemorrhagic drugs. 

8. ' Miscellaneous drugs, such as ^lucoSe, glucose -saline injections, 

cholesterol, liver preparations, numerous vitamins, alcohol, 
insulin, corpus luteum hormone, Congo red desoxycorticosterone 
acetate (DCA), and ACTH. 

9. Blood transfusions. 

{Williams, E.G., Ingraham II, S. C. , Biological MedicalConsiderations in 
Atomic Defense: Pub. Health Rep. , 71: 174-180, February 1956) 



Medical News Letter, Vol. 27, No. 6 



7 



Thoracic Pain in Cardiovascular Disease 

Thoracic pain of cardiovascular origin may result from myocardial 
ischemia, pericardial irritation, or certain diseases of the aortic arch 
system when several mechanisms of producing pain may come into play. 
Many other types of pain occur in, or are referred to, the thoracic region, 
so that the same patient may experience several types of pain. For example, 
he may experience pain because of coronary insufficiency, gallstones, or 
an esophageal hiatal hernia; he may have musculoskeletal pain in various 
parts qf the thoracic cage. 

Pain of myocardial ischemia, namely, angina pectoris, is most 
frequently caused by disease of coronary arteries, but it may be caused by 
aortic insufficiency or stenosis due to valvular aortic disease including 
syphilitic aortitis. 

The character of the pain of myocardial ischemia is essentially the 
same regardless of the cause of the ischemia. The duration and intensity 
of the pain, however, vary imder the different circumstances in which angina 
pectoris occurs. 

Angina of Effort . The chief characteristics of angina of effort are: 

1. Its onset and cessation are related respectively to increase and 
decrease in cardiac work. Increase in cardiac work occurs during physical 
exertion, as a result of excitement, after eating a meal, and in cold weather. 

2. The typical distribution of the pain is retrosternal, not precordial. 
In most cases, it tends to appear in the midline behind the sternum, in the 
epigastrium, or in the throat, and to spread centrifugally. It may extend 
into the ulnar side of the left arm, less often to both arms, to the right 
arm alone, or into the lower jaw. Occasionally, it starts in the arm or 
arms and spreads centripetally to the regions just mentioned. The pain 
may be felt only in the wrists or only in the upper part of the abdomen. 

3. The onset of the attack is abrupt and its duration is short. It 
usually lasts less than 5 minutes. A small percentage of patients do des 
cribe their pain as precordial, that is, in the left anterior portion of the 
thorax, but all the other criteria mentioned, especially the relation of pain 
to effort, hold true. 

4. Vasodilating drugs such as glyceryl trinitrate and amyl nitrite 
terminate the pain more quickly than rest alone, and at times the response 
of thoracic pain to these drugs is helpful in differential diagnosis. 

5. Provocative tests may be resorted to in doubtful cases in the dif- 
ferential diagnosis of thoracic pain. The exercise test has almost com- 
pletely replaced the hypoxia test in this regard, but with either method, 
production of the patient's pain or significant electrocardiographic changes, 
or both, may be of great help in the differential diagnosis of thoracic pain. 

Angina Associated with Myoca rdial Infarction, The pain resulting 
from acute coronary occlusion with myocardial infarction has all the 



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Medical News Letter, Vol. 27, No. 6 



characteristics of angina of effort. It is, however, more severe and more 
prolonged in most instances; it is not so readily relieved by vasodilating 
drugs; it may occur while the patient is at rest or even in the course of 
sleep. 

The symptoms of myocardial infarction vary from mild attacks of 
"acute indigestion" to severe seizures. The mild attacks, called "acute 
indigestion, " are really episodes of anginal pain which is referred to the 
epigastrium or lower part of the sternum; they last 15 to 30 minutes and 
gradually disappear. The severe seizures may last many hours and may 
be associated with all the signs of severe shock. In other cases, the attack 
is represented by an episode of severe dyspnea, with or without evidence 
of acute left ventricular failures, and with complete absence of pain, or at 
the most, a mild sense of burning. Except in the milder attacks, the patient, 
usually looks anxious, as in all vascular occlusions, perspires freely, has 
an ashen color and a decrease in the blood pressure. Occasionally, the 
blood pressure is elevated at first, and later drops. The last is a peri- 
pheral vascular phenomenon associated with shock. The heart sounds often 
reveal nothing significant although, at times, they may be fainter than before; 
gallop rhythm may be present and, in a few cases, ectopic rhythm develops. 
Frequent extrasystoles may precede such an episode of ectopic rhythm. 

In the succeeding hours, moderate temperature and leukocytosis 
develop; the sedimentation rate begins to be accelerated after 24 hours, al- 
though this may be delayed for days. If the anterior surface of the left ven- 
tricle is involved, a pericardial friction rub may appear. This finding 
indicates localized pericarditis over the site of the infarct. The duration 
of the symptoms of shock varies with the severity of the attack and with 
the response to treatment. The temperature tends to become normal after 
a few days. 

Electrocardiographic manifestations indicative of acute myocardial 
infarction may be present shortly after the onset of the attack, or they may 
be delayed for many days. 

The pain of pericardial irritation is one of the classical manifestations 
of acute pericarditis. Pericarditis, however, may occur without pain. It 
may occur as a complication of pneumonia and septicemia or as part of the 
clinical picture of rheumatic fever, tuberculosis, disseminated lupus ery- 
thematosus, myocardial infarction, or uremia. Another type of pericar- 
ditis, spoken of as "nonspecific pericarditis, " may occur without any 
specific demonstrable etiologic factor. This type of pericarditis frequently 
develops shortly after an infection of the upper part of the respiratory tract 
and eventually ends in complete recovery. 

The pain of pericarditis may be spread over the whole thorax or it 
may be localized in the substernal, pericardial, epigastric, or intrascapu- 
lar regions. It may extend into the neck and occasionally into the arms. 
It has been described as "aching" or "squeezing" and is characteristically 



Medical News Letter, Vol. 27, No. 6 



9 



aggravated by breathing, coughing, twisting of the torso, and swallowing. 
The presence of pericarditis is further corroborated hy the presence of a 
pericardial friction rub, by certain roentgenologic and electrocardiographic 
findings, or by recognition of the primary disease responsible for it; it 
should be recalled, however, that in so-called acute nonspecific pericar- 
ditis, no evidence of a primary disease can be demonstrated. 

The roentgenologic finding most suggestive of pericarditis is increase 
in the size of the cardiac silhouette. This rnay be attributable to increase 
in the quantity of pericardial fluid, to cardiac dilatation, or to both factors. 

Pain may result from valvular aortic disease, including syphilitic 
aortitis. Two other types of pain arising from aortic disease, however, 
require special mention. 

Pain from a Dissecting Aneurysm of the Aorta . Pain resulting from 
a dissecting aneurysm of the aorta may be indistinguishable from that owing 
to coronary occlusion. Aneurysm, therefore, can be suspected if repeated 
electrocardiograms remain imchanged after attacks which clinically have 
the hallmarks of myocardial infarction, especially if the pain is referred 
to the upper thoracic vertebrae, and if there is roentgenoscopic evidence 
of progressive changes in the configuration of the aortic arch. The occur- 
rence of transient neurologic signs and symptoms among patients who have 
prolonged attacks of anginal pain is further strongly suggestive evidence 
of dissecting aneurysm of the aorta. 

Pain Associated with Large Aneurysms of the Aorta . Large aneurysms 
may cause pain by eroding adjacent bony structures, such as the sternum, 
ribs, or thoracic vertebral bodies, by pressure on nerve roots, and by dis- 
placement of intrathoracic viscera. Fortunately, aneurysms of the aorta 
rarely are seen nowadays because syphilis, one of their frequent causes, 
is now effectively treated in its early stages. 

The pain resulting from erosion of bone is persistent and may be 
distressingly severe. In the process of erosion, nerve roots are exposed, 
and pain results in the distribution of the involved nerve root; character- 
istically, the pain is worse at night. Dysphagia represents the type of pain 
resulting from displacement of, and obstructing effects on, the esophagus. 
The diagnosis of large aneurysm usually is obvious from roentgenograms 
of the thorax and from the mechanical effects of the aneurysm itself. 

Angina pectoris, the commonest and certainly the most important 
type of thoracic pain associated with cardiovascular disease, is usually 
readily identified and distinguished from other types of pain by its character- 
istic distribution and its strict relation to increased cardiac work. 

Esophageal pain and pain associated with diaphragmatic hernia may 
closely simulate angina pectoris; root pain of cervical and upper thoracic 
origin is mistaken for anginal pain; biliary colic, acute pancreatitis, and 
perforation of abdominal viscera have been mistaken for acute myocardial 
infarction. Spontaneous mediastinal emphysema can simulate acute myo- 
cardial infarction very closely. Clinically, the syndrome is characterized 



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Medical News Letter, Vol. 27, No. 6 



by substernal or precordial pain which, when it begins suddenly and extends 
to the left shoulder, into the neck, or down the left arm, is easily mistaken 
for acute myocardial infarction. A peculiar crunching sound is heard over 
the precordium during both phases of the cardiac cycle. A positive diagnosis 
can be made by the roentgenographic demonstration of the presence of air 
in the mediastinum and by the absence of other evidence of myocardial in- 
farction. 

Various local conditions of the thoracic wall, such as myositis, and 
arthritis of the spinal column are only too frequently labeled coronary dis- 
ease. Skeletal and muscular pain may be brought on or aggravated by effort, 
but they are not so closely related to exertion as is anginal pain. Skeletal 
and muscular pain caused by effort tend to last much longer than angina 
from effort lasts ordinarily. Use of the upper extremities, furthermore, 
is more likely to cause skeletal and muscular pain than is walking. Finally, 
when a patient complains of rheumatic types of pain, evidence of a similar 
disturbance elsewhere frequently may be found. The muscles about the 
shoulder girdle and the tissues overlying the sacroiliac joints should be 
palpated carefully to detect the presence of tender fibrositic nodules. Musculo- 
skeletal pains about the thorax frequently extend into either or both arms, a 
fact that is frightening because most laymen seem to believe that pain which 
extends in this fashion is always caused by cardiac disease. (Dry, T. J. , 
Thoracic Pain in Cardiovascular Disease: Proc. Staff Meet. Mayo Clin. , 
3j_: 10-15, January 11, 1956) 

j): 4: sS; ;{< ^ 

Artificial Pneumoperitoneum 

Because the proper place of pneumoperitoneum in pulmonary tuber- 
culosis has been held in question by many, the authors have attempted 
through this study to evaluate their experience with the procedure on the 
Tulane service of Charity Hospital of New Orleans. There are staunch 
advocates of its use in nearly all cases of tuberculosis, and there are 
still other physicians who have given it a trial and discarded it in favor 
of surgical procedures. 

In the treatment of pulmonary tuberculosis, is is well to remember 
that there will always be some patients who will recover no matter what 
form of therapy is used and pneumoperitoneum in such cases will almost 
surely help the majority. On the other hand, there will be those patients 
referred to as "last resort" cases, who are clinically and roentgenologi- 
cally far advanced, and in whom other types of collapse therapy (expecially 
pneumothorax) or surgery are contraindicated, and in most of them pneumo- 
peritoneum is surely doofned to fail. Therefore, in the evaluation of the 
procedure, it is essential to take into consideration a number of variables. 



Medical News Letter, Vol. 27, No. 6 



11 



namely, type of lesion {exudative, fibrotic, mixed), extent of lesion 
(minimal, moderately advanced, far advanced), location (upper one -third, 
lower two -thirds, or both upper and lower areas), duration of treatment 
and supplemental therapy. 

Of 173 cases who received pneumoperitoneum, only 90 (5Z%) were 
considered complete enough for evaluation and analysis. The remaining 
83 were considered incomplete because of lack of follow-up after hospital 
discharge or inability to locate the roentgenograms of the hospitalization 
period. These 90 cases were treated with pneumoperitoneum alone, or 
with pneumoperitoneum and phrenemphraxis either with or without anti- 
bacterial drugs. 

The range of use of pneumoperitoneum was fairly broad and the indi- 
cations were: (1) definitive therapy, (2) pneumothorax failure, (3) tuber 
culous pneumonias, (4) holding procedure until surgery became advisable, 
and (5) last resort. 

Those cases of minimal, moderately advanced or far advanced cases 
in which pneumoperitoneum was used as a definitive method of treatment 
comprised that group in which the hospital staff felt pneumoperitoneum 
was the method of choice of all forms of therapy. The pneumothorax 
failure group is self explanatory. The group of tuberculous pneumonias is 
not included in this study and has been reported separately. Those cases 
of unilateral cavitary disease where surgery was indicated, but the patient's 
condition did not allow the procedure at that time, were given pneumoperi- 
toneum as a temporizing or holding procedure, usually for at least 8 to 12 
months. These cases comprise the fourth indication. The last group em- 
braces those with far advanced, bilateral cavitary disease where surgery 
is inadvisable due to low pulmonary reserve or poor risk, and where other 
forms of collapse therapy are contraindicated. In this last group, pneumo- 
peritoneum was actually used as a "last resort" procedure. for the sake of 
offering the patient something in addition to bed rest. The authors do. not 
advise administering pneumoperitoneum routinely in all such cases, but 
these last ones were so grouped in order to evaluate the effect of pneumo- 
peritoneum. 

The over -all results of pneumoperitoneum were classified as improved 
(inactive or arrested NTA classification 1950), active (retrogressing), active 
(progressing), or dead . The criteria used for improved were (1) all cavities 
closed; (2) sputum converted to negative by concentrate (arrested) or by cul- 
ture (inactive). The active group included those which did not fulfill the 
requirements for the improved group, and in which the lesions were retro- 
gressing or progressing. Retrogression implied closure of some, but not 
all cavities, reduction in cavity size, extensive clearing of the pulmonary 
infiltrative lesion, and sputum which was either negative or positive. Pro- 
gression implied that there was no benefit to either the cavities or the 
infiltration, that the lesion had increased in extent, and the sputum was 
usually positive. 



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Medical News Letter, Vol. 27. No. 6 



The duration of pneumoperitoneum in all of the 90 cases varied 
from 3 to 60 months, in 8 cases, the duration of pneumoperitoneum was 
less than 9 months and all had unfavorable results. Seven are dead and 
pneumoperitoneum was used in all as a last resort. One case is active 
progressing; in this case pneumoperitoneum was used as a definitive 
measure. The average duration of pneumoperitoneum in the improved 
group was approximately 2 years (23. 7 months). It was noted in those in 
whom improvement was to be found that clearing of the exudative compon- 
ent and closure of the cavities appeared within 8 or 9 months (average 8. 6 
months) after the induction of pneumoperitoneum. It was apparent that by 
that period of time one could form an opinion as to whether the disease pro- 
cess was actually responding to treatment. It is felt that once pneumoperi- 
toneum is begun it should be continued for at least 9 months before deciding 
to abandon it. The average time for conversion of the sputum to negative 
was 11.4 months after initiation of pneumoperitoneum. 

Pneumoperitoneum was apparently a safe and easy procedure in this 
series. Complications were few and of seemingly little consequence. Ab- 
dominal discomfort was occasionally noted, but to no great extent. The only 
complication of real significance was ascites which occurred in only 5 of the 
173 cases. 

Pneumoperitoneum proved to be of definite value with regard to cavity 
closure and its therapeutic effectiveness was enhanced by antibiotics. 
(Cabiran, L. R. , Goldstein, N. , Artificial Pneumoperitoneum in the Treat- 
ment of Pulmonary Tuberculosis: A Clinical Study: Dis. Chest, XXIX : 
202 212, February 1956) 

The Nonhospitalized Tuberculosis Patient 



Changing emphases and concepts in the tuberculosis problem in the 
United States have given rise to a variety of assumptions not supported by 
valid evidence. The paucity of precise evidence concerning the character- 
istics and status of tuberculosis patients, who are not hospitalized, has per- 
mitted unsubstantiated conjecture so conflicting in nature as to limit the 
effectiveness of program planning. The Public Health Service has, therefore, 
undertaken to provide statistical data that will reliably describe the current 
status of known nonhospitalized tuberculosis patients in sample areas of the 
continental United States, so that health departments and other tuberculosis 
control agencies may have a foundation of specific information on which to 
construct plans for the effective use of funds, facilities, and operations. 

The purpose of this study is to observe the characteristics of non- 
hospitalized tuberculosis patients who are in need of intensive public health 
supervision and to give information on the types of care and services given them. 



Medical News Letter, Vol. 27, No. 6 



13 



By means of sampling techniques, 37 areas of the United States were 
selected. Together, these areas constitute an unbiased sample census of 
the number and status of known nonhospitalized cases for the United States 
as a whole. The nation was divided into three population groups and further 
subdivided into areas of suitable administrative size ranging from 50,000 
to 600,000 population. For the largest cities, a part of a city constituted 
an area. In sparsely settled regions, four or more counties combined to 
make an area. 

For purposes of analyzing the latest status of disease activity, the 
cases were divided into three activity groups: (1) active and probably 
active, seen in past year; (2) presumably active, current activity status 
indeterminate; (3) arrested or inactive, with drugs prescribed. 

According to the latest information at the time of the study, 55% of 
the significant case load was hospitalized; 45% was not hospitalized. Plain- 
ly, this situation has many implications for health departments and other 
agencies. Certainly, the community has as great a responsibility for those 
cases outside hospitals as for those that are hospitalized. Because of the 
attendant difficulties involved in supervising patients who are not in insti- 
tutions especially designed for their care, medical, nursing, and social 
services will be particularly challenged. Health departments will be ad- 
ditionally concerned about the chances of spread of the disease because of 
the presence of active cases in their communities. 

By means of sampling techniques, 37 areas of the United States were 
selected. These areas had a total population of almost 7 million and consti- 
tute portions of 24 states. 

Roughly, one -half (55%) of the significant case load is in hospitals, 
and, roughly, one-half (45%) is at home. Of those at home: (1) Three fourths 
have been known to health departments for less than 5 years. (2) One-half 
are 45 years of age and older. (3) In the age groups over 35, there are more 
than twice as many males as females. (4) Eighty-seven percent are in ad- 
vanced stages of disease. (5) Sputum status is unknown in almost one-half. 
(6) One-third are reported as under care of private physicians. (7) Forty- 
four percent of active cases have had drugs recommended; 40% of active 
cases have had neither drugs nor bed rest recommended. (8) Three -fourths 
of all cases had a history of previous hospitalization. (9) Almost one -half 
of all cases in the study were discharged from hospitals against medical 
advice. (10) For one-fourth of active cases, the supervising agencies were 
unable to obtain information about recommendations for hospitalization. 
(11) Two-thirds of the patients were not hospitalized because of medical, 
personal, and family preferences. 

The availability of clinic, public health nursing, and social services 
is directly related to density of population; in rural areas, almost one-half 
of the study population had no clinic services; 10% had no public health 
nursing services; 80% had no social services other than financial assistance 



14 



Medical News Letter, Vol. 27, No, 6 



as provided by departments of public welfare. ( Blotnquist, E. T. , The 
Nonhospitalized Tuberculosis Patient: Am. J. Pub. Health, 46; 149-155, 
February 1956) 

****** 
Acerola Juice 

The juice of the Puerto Rican cherry has from 50 to 100 times the 
vitamin C content of orange juice (4000 mg. per 100 ml. compared with 
40). It can be taken as a natural juice, or because of its very high vitamin 
C potency, it can be used to blend with any juice, food, or liquid that con- 
tains little or no vitamin C. It could be valuable in any disease requiring 
large doses of vitamin C. The potentialities are unlimited for its use as a 
valuable food supplement as well as to enrich by blending with any low 
vitamin C product. 

This study was made to determine the value of acerola juice as a 
source of ascorbic acid (vitamin C) in the diet of normal infants. 

The Puerto Rican cherry or acerola grows semi-wild and is native to 
tropical and subtropical America, especially in the Caribbean area. Because 
of its favorably physical characteristics, it lends itself to intense cultivation 
and industrialization. The acerola is a small tree or shrub 4 to 10 feet high. 
The fruit is a pseudo-cherry not related to the classical cherry (prunus). 
The tree has waxy green leaves, white and orchid colored blossoms and 
bright "cherries" when ripe. The fruit is fleshy and drupaceous. The cherry 
weighs between 7 and 12 gm. and measures approximately 2 to 3 cm. in dia- 
meter. The fruit contains from 1 to 3 gm. of ascorbic acid per 100 gm. or 
1 to 3% of the edible matter. The green fruit contains more ascorbic acid 
than the ripe — frequently twice as much. The juice has a reddish orange 
color and an agreeable tart taste. The average cherry contains 53 to 70 mg. 
of vitamin C. It requires from 1 1 to 25 cherries to supply 100 cc. of juice 
which contains from 1400 to 2000 mg. of vitamin C. 

Thirty infants were studied for a 12-month period. May 1954 through 
April 1955. Their ages varied from 1 to 6 months when the acerola juice 
was started as their only form of vitamin C. There were three premature 
infants. The special acerola blended juice was fed to two classes of infants: 
(1) normal newborn infants who were started on the acerola vitamin C at 
1 month of age; and (2) infants under 6 months who were either clinically 
allergic to orange juice or who had some previous allergic manifestations 
such as eczema, pylorospasm, or severe colic (i. e. mild allergy). 

It is common knowledge among pediatricians that orange juice is 
probably the most frequent allergic sensitizer of any food used in early 
infant feeding. As a consequence, in many cases, especially in allergic 
families, parents are advised not to use orange juice until the baby is 9 or 



Medical News Letter, Vol. 27, No. 6 



15 



10 months old. At this time, the infant appears to develop an immunologic 
immunity to some of the common foods. This product is also useful for 
those who dislike orange juice or cannot take it for one reason or another. 

Acerola is the richest known source of vitamin C, having from 50 to 
100 times the ascorbic acid content of orange juice. Thirty infants, ranging 
in age from 3 to 7 weeks were given acerola juice as the only significant 
source of ascorbic acid in their diet. All infants showed average or better 
growth and development for their age and weight. Ascorbic acid levels in 
the blood plasma of all infants were above average after the acerola juice 
was introduced into the diet. No reactions occurred from ingestion or from 
skin and intradermal tests with acerola juice. Acerola juice can be blended 
with apple juice which is naturally low in vitamin C, and is used to satisfy 
the ascorbic acid requirements in infant feeding. It is particularly valuable 
in infants who are allergic to orange juice or where the family allergic his- 
tory deems it advisable to delay giving orange juice until one year of age. 
(Clein, N. W. , Acerola Juice — The Richest Known Source of Vitamin C: 
J, Pediat. , 48_; 140-144, February 1956) 

Lumbar and Sacral Compression Radiculitis 

This study is concerned with certain back injuries, having to do with 
ruptured intervertebral disks as well as the compressive radiculitis in the 
same area, that were admitted to the neurosurgical service of the Boston 
City Hospital during the 17 years, 1937 - 1955. The total number of patients 
was 545 ranging in age from 15 to 68 years. There were 402 men and 143 
women; 124 patients had had multiple admissions, the greatest number per 
patient being 14. 

The possible causes of the injuries resulting in a compressive lumbar 
radiculitis, and commonly associated with ruptured lumbar or lumbosacral 
disks, are legion. They range from no known cause through athletics, jujit- 
su, and post-partum back strain, to getting into or out of bed. 

It is apparent from this analysis that, while almost any bodily activity 
can produce back alterations that lead to compressive radiculitis, the com- 
monest causes and, therefore, the ones that should raise a suspicion of 
such an injury in the surgeon's mind, are lifting, a fall, and "no cause. " 

It is well known that, in the opinion of many surgeons, it is possible 
in the group in question, to make an accurate unaided clinical diagnosis of 
the pathology present and requiring therapy. This is done without such 
mechanical aids as a myelogram, and such a diagnosis will commonly be 
described as an extruded or protruded ruptured intervertebral disk. This 
is not in accord with the experience of the authors. Roughly, one fifth of 
their cases without ruptured disks showed the same signs and symptoms 



16 



Medical News Letter, Vol. 27, No. 5 



that are commonly found in ruptured 4-5 lumbar and lumbosacral disks. 
The only significant exceptions were patients with pseudarthrosis of the 
spinous processes and the patient with the thrombosed caudal vein. 

This diagnostic unreliability of clinical signs and symptoms has been 
pointed out previously. As a result of this experience, the author believes 
that the patient with such suggestive signs and symptoms should be given 
the benefit of every appropriate diagnostic procedure and in many instances 
should be offered an exploratory diagnostic operation after a period of proper 
conservative therapy if he is still disabled by his symptoms, and particularly 
if he has had a previous so-called disk operation. The frequency with which 
a previous operative scar, a tight dural sheath or root canal, or a narrowed 
spinal canal {all virtually unrecognizable except at operation) have been found 
to be the sole cause of the original or recurrent symptomatology is too great 
to be disregarded. As a corollary to this, it is essential to determine during 
the operation by palpation with an angulated instrument inserted intradurally 
into the sheath or extradurally into the root canal whether or not either of 
these structures is the proximate cause of any compressive radiculitis 
whether they exist alone or in conjunction with an actual protrusion or ex- 
trusion of a nucleus pulposus. 

There can be no doubt that patients, complaining of low back pain 
whether classed as industrial or nonindustrial injury, should be given the 
benefit of a long enough period of conservative nonoperative therapy so that 
the physician in charge can be relatively sure that relief of symptoms and 
invalidism cannot be cured without operation. Such measures as bed rest, 
traction, hyper extension of the spine, massage, manipulation, injection of 
Novocain or its derivatives into spastic muscles, judicious exercise, muscle 
stretching and muscle building must be given a fair trial. A careful hospital 
study of other possible causes, such as spondylolisthesis, pseudarthrosis 
of spinous processes, hernias through the lumbar fascia, tuberculosis, flat 
feet as well as bad posture, tumors, congenital defects and so forth, must 
be carried out and the patient's treatment appropriately modified so that 
these causes can be ruled out. Only then can one properly decide to operate 
on such a patient for a ruptured disk or a compression of a root or roots. 

In the author's experience, the convalescent care of patients that 
have been adequately operated upon for compressive radiculitis is as impor- 
tant as the operation insofar as remission of invalidism and return to work 
are concerned. There can be little dispute with the point of view that in 
such patients the paraspinal muscles before operation are in spasm and 
anatomically shortened. They have a varying degree of atrophy of disuse 
and are, therefore, weak. The supporting vertebral ligaments are required 
to do more than they were constructed to do and back motion is splinted and 
painful. There is almost always present the continuous nagging pain of an 
irritated compressed spinal root with resultant concentration of the patient's 
attention on this rather than his work. Finally, virtually complete invalidism 



Medical News Letter, Vol. 27, No. 6 



17 



and lack of muscular effort with a high degree of psychoneurosis develops. 
This is heightened further by the fact that almost always he has had attacks 
similar to the one that led to the operation, but has previously recovered 
from them even though the doctors offered no effective therapy and often 
insisted that he waste time, effort, and money in treatment that he was 
convinced was useless — an opinion that had been borne out by his exper _ 
ience through the years. In short, these conditions require postoperative 
convalescent therapy which must first stretch and strengthen the shortened 
weak muscles locally, must simultaneously provide a method of rebuilding 
the body and its more active functions generally, and finally, must do so 
by the patient's own efforts. Only in this way, will the patient be persuaded 
to be cooperative and intelligent about his problem and at the same time have 
no one to blame or to provide an alibi in case of failure except himself. Only 
thus, can permanent invalidism, neurosis, and a whole train of similar dis- 
abilities be done away with. 

Along with this positive point of view, there is an equally important 
negative attitude. Certain procedures must not be carried out on these 
patients. The more important are: no formal exercise while the patient is 
bed ridden after operation. There is too much danger of unrecognizable 
deep hemorrhage with a resultant scar. Patients must not get out of bed 
later than 8 or 9 days, but must then start active ambulation; they must not 
be discharged from the hospital until they can walk up and down two flights of 
stairs in succession. Their formal convalescent regimen must not be started 
until after they have been home for two weeks. Light therapy, diathermy, 
massage, passive and assisted active motion, whirlpool or other baths and 
synthetic exercise in any form are not only contraindicated, but in the author's 
experience, have been definitely harmful. If any local muscle -building exer- 
cises are needed, they must be done by the patient himself in such a way as 
to mimic normal functional use and activity. 

After two weeks at home, the patient should report to his surgeon. 
The latter can then outline a convalescent regimen that will meet the fun- 
damental requirements stated above. The author accomplished all that is 
necessary along these lines by explaining to the patient that to stretch his 
shortened, still spastic muscles he must bend at his waist forward, back- 
ward, and to either side ten times every morning right after he gets out of 
bed. More bending than this is harmful and less is ineffectual in any 24- 
hour period, provided that at each bend the patient goes far enough to feel 
his back and thigh muscles stretch, that he keeps his knees straight and 
holds his hands on his hips. He is also told to take walks which must be 
gradually increased in length until he is walking 5 miles twice every day. 
These walks must each be of such length that the patient is not exhausted, 
but does feel that he has had definite progressively greater and greater 
exercise. 



18 



Medical News Letter, Vol. 27, No. 6 



The patient should report to his surgeon not oftener than once in 
every two or three weeks, and should be physically in condition to return 
to work in 8 to 10 weeks after leaving the hospital. He should develop no 
neurotic tendencies and should be willing, and will be physically able, to 
do any kind of job that does not require lifting, jumping, pulling, pushing, 
or working with his back in a strained unnatural position for even relatively 
short periods. These limitations will apply for the rest of his life at work 
and at home. They are designed to prevent recurrence of any condition 
that can produce a compressive radiculitis, to prevent the redevelopment 
of spasm in any of the bodily musculature and to make the patient person- 
ally responsible for his own recovery and welfare and, thus, deprive him 
of the opportunity of using alibis provided by others, and yet prevent him 
from being put, or from putting himself, into such positions as have already 
been demonstrated to be unfavorable to his physical welfare. It should be 
repeated that this convalescent treatment is predicated on the assumption 
that the previously compressed root or roots have been decompressed. If 
they had not been, no variety or amount of convalescent therapy will relieve 
the patient of his symptoms, stop his invalidism, or return him to gainful 
labor. (Munro, D. , Lumbar and Sacral Compression Radiculitis - Herniated 
Lumbar Disk Syndrome: New England J. Med. , 254: 243-251, 9 February 
1956) ~~ 

:jc 3ic ^ ^ 

Gastric Polyps and Adenomas 

The establishment of adequate information on the relationship of the 
precursor lesion, gastric adenoma, to gastric cancer should be one of the 
essential steps in lowering the death rate from gastric malignancy. The 
elimination of these lesions requires gastrotomy, partial gastrectomy, 
or even total gastrectomy. Often, the decision for operation is based on 
symptoms of obstruction or bleeding. More often, the lesion is found in 
the routine examination of patients without ominous symptoms and the de- 
cision for operation must be based on the probability of the polyp being 
malignant or becoming malignant. A single gastroscopic or roentgenologic 
examination may not be adequate to determine the probably benign nature 
of the lesion or even to establish the diagnosis of a probable adenoma as 
contrasted to a foreign body, hypertrophic gastritis, or leiomyoma. 

Polyp is used to describe the lesions clinically diagnosed and adenoma 
to describe the lesions pathologically proved. 

The group of patients previously reported have been traced for 5 
additional years. The groups are presented as they were in the original 
report. Thus, Group I contains the patients treated by observation. The 
patients who have been operated upon in the 5 -year interval will be noted 
and summarized. 



Medical News Letter, Vol. 27, No. 6 



19 



The benign nature of gastric polyps is attested to by the fact that 
none of the patients with benign polyps developed symptoms of obstruction 
or bleeding during this 5 year period. The several operations performed 
were carried out because of the probability of malignant change. 

The frequent association of benign gastric adenomas and gastric 
cancer, as well as the occasional finding of a malignant area in a benign 
adenoma, establishes the precancerous nature of gastric adenomas. Oc- 
casional cases have been reported where carcinoma was found in the loca- 
tion of a previous gastric polyp. 

Earlier reports of the frequency of malignant change in large gastric 
polyps ranging from 9 to 40% were correct. However, because more roent- 
genographic and gastroscopic studies of the stomach are done in patients 
with mild symptoms, the small asymptomatic polyp is being recognized. 
The chance of malignancy in these is less. Only one of the 81 lesions less 
than 2 cm. in diameter was malignant while 6 of 14 lesions over 2 cm. in 
diameter were malignant. 

The author's experience would indicate that a diagnosis of a benign 
polyp by the roentgenologist and/or gastroscopist is rather reliable. Repeat 
examination of the presumed benign lesions for growth, infiltration, or other 
signs of malignancy during the first year or so will minimize diagnostic 
errors. 

The nonoperative or observation type of management is recommended 
in asymptomatic or mildly symptomatic patients with polyps less than 2 cm. 
in diameter which appear benign to the gastroscopist and roentgenologist. 
These patients are observed by roentgenologic or gastroscopic examination 
every 3 or 4 months for the first year, and then biannually. The probability 
of malignancy as indicated by an increase in size of the lesion, infiltration 
of the gastric wall, or increased nodularity and pallor of the surface of the 
lesion indicates the need for operative treatment. 

The following groups of patients should be subjected to operation: 
(1) patients with polyps larger than 2 cm. in diameter; (2) patients with 
polyps smaller than 2 cm. in diameter in which the roentgenologist or 
gastroscopist suspects malignancy; (3) patients with clinical symptoms due 
to polyps if the symptoms arfe of a severity to justify the risk of operative 
intervention; and (4) patients who refuse, or are unable, to accept adequate 
observation because of geographic or personal reasons. (Hay, L.J. , 
Surgical Management of Gastric Polyps and Adenomas: Surgery, 39: 114- 
118, January 1956) 



i{c if: :^ 3[: :^ 



20 Medical News Letter, Vol. 27, No. 6 

Thromboembolic Disease in Obstetrics and Gynecology 



By the early diagnosis and adequate treatment of thromboembolic dis- 
ease, several worthwhile objectives are achieved: reduction in the incidence 
of fatal pulmonary emboli; prevention of chronic venous insufficiency and its 
sequelae (edema, pain, varicosities, skin changes, and ulceration) and, 
finally, thromboembolic disease. This last point is of importance because 
of the emphasis that has been placed on the expense of anticoagulant therapy. 
With these objectives in mind, this survey of the 101 cases of thromboem- 
bolic diseas e, occurring inobstetric and gynecologic patients at the Temple 
University Hospital over a 3-year period, was undertaken. The incidence 
of thromboembolic complications following cesarean section and major gyne- 
cologic surgery was identical, 1. 81%. Of these patients, 23 had some form 
of heart disease, 31 were obese, and 36 had varicosities of the lower extre- 
mities. Other contributing factors were anemia in 14, excessive blood loss 
in 17, and postoperative or postpartum infection.. 

Within certain limitations, anticoagulants are now regarded as the 
specific therapy for thromboembolic disease. It is not unusual, however, 
for anticoagulant treatment to be delayed until the signs and symptoms are 
"more definite" in the hope that the condition will subside spontaneously. It 
is well known that this delay exposes the patient to an increased danger of 
pulmonary emboli; however, the effects of this delay on the duration of the 
disease and the hospital stay tend to be overlooked. In order to determine 
the effects of this delay on the duration of the disease, and the length of hos- 
pitalization, the patients were divided into 3 groups on a basis of the time 
at which anticoagulant therapy was begun. Those cases in which there was 
no delay in diagnosis and in which anticoagulant therapy was begun immed- 
iately were placed in Group I. Those in which there was a delay of from 1 
to 2 days in initiating treatment were placed in Group Ii; and Group III 
included all cases in which treatment was begun more than 2 days after the 
initial symptoms. The duration of the disease was determined from the time 
of the first sign or symptom to the absence of any objective signs of disease 
activity. Because of insufficient data, only 67 of the 101 cases are included. 
The cases are almost evenly divided between the two services. 

Because the early diagnosis and initiation of active adequate therapy 
are important, some of the aspects of diagnosis and therapy in obstetric 
and gynecologic patients must be discussed since they may differ somewhat 
from those in the medical or general surgical patient. In these patients, 
tenderness over the involved veins was the one most reliable diagnostic 
sign. The most frequent site of tenderness was the middle third of the calf, 
although the femoral and pelvic veins were frequently involved. The femoral 
vein can be isolated just medial to the pulsation of the femoral artery in 
Scarpa's triangle and the tenderness here is practically pathognomonic of 
femoral thrombophlebitis. Occasionally, the physician is lulled by the 



Medical News Letter, Vol. 27, No. 6 



21 



absence of fever, yet 23 patients had no temperature elevation either at 
the onset or during active recurrences of the disease. Six of the ten pre- 
< natal patients were in this group. The time of onset was variable, averaging 

5. 5 days following operation or delivery; 40 cases began within the first four 
postoperative or postpartum days. 

The diagnosis of pelvic thrombophlebitis was especially difficult and 
was often delayed. The lesion was usually recognized after failure of res- 
ponse to therapy for endometritis, parametritis, cellulitis, or pelvic peri- 
tonitis. Nine of the thirteen patients with pelvic thrombophlebitis had one 
of the above infections, but despite antibiotic therapy the fever subsided 
only after an adequate level of anticoagulants was obtained. 

The fundamental principles of therapy consist of treatment directed 
toward prevention of the propagation and dislodgment of the clot. These are 
accomplished by attacking the clotting process with the immediate adminis- 
tration of Heparin and Dicumarol and by increasing the circulation of the blood 
in the extremities with the Trendelenburg position. In addition to the anti- 
coagulant therapy, antibiotics should be administered. 

When pain is severe, paravertebral block usually gives dramatic 
relief; procaine (0. 5 gm. in 500 cc. fluid) intravenously given over a 20 - 
minute period is less effective and of shorter duration. Spinal anesthesia 
is inferior to either; although it relieves the pain temporarily, it causes 
muscular paralysis and pooling of blood in the lower extremities, thereby 
increasing stasis. Neither paravertebral block nor spinal anesthesia should 
be used, however, after anticoagulant therapy has been initiated. 

When the symptoms begin to subside, the patient should begin active 
leg exercises, but should remain in bed until the signs and symptoms are 
absent, the temperature is normal for a 24-hour period, and the anticoagu 
lant level is adequate. If edema is present on arising, an Ace bandage is 
applied. Heparin, when used alone, must be continued in therapeutic amounts 
at least for 24 hours after ambulation and in decreasing amounts for 2 or 3 
days. Dicumarol should be continued in therapeutic dosage approximately 
5 to 7 d&ys after ambulation and in slowly decreasing amounts thereafter 
for a total of 3 to 4 weeks of treatment. Once the patient's response to 
Dicumarol is evaluated in the hospital, it can be continued with relative 
safety after discharge with regular prothrombin checks. {Burns, W. T. , 
Thromboembolic Disease in Obstetrics and Gynecology: Am. J. Obst. & 
Gynec, Ti_: 260-265, February 1956) 

^ 9i: »}: :{( 

Please forward requests for change of address for the News Letter to: 
Commanding Officer, U.S. Naval Medical School, National Naval Medical Center , 
Bethesda 14, Md. , giving full name, rank, corps, and old and new addre s ses . 



22 



Medical News Letter, Vol. 27, No. 6 
Notice to All Military Service Members of the A. M A. 



Each year a large percentage of membership cards sent to military 
service members are returned to the Membership Department at A. M. A. 
headquarters because the address is incorrect. Beginning in 1956, service 
membership cards will not be sent to service members until the member has 
sent a postcard or a letter informing this office where the card is to be sent. 
In this way the member will be sure of receiving his membership card, and 
it will obviate further correspondence in order to try to find out the proper 
address of the member. 

:^ 9}: >!s X< 4 

Reunion at National Naval Medic al Center 

A reunion of officers attached to the National Naval Medical Center 
during the period, 7 December 1941 to 15 August 1945, is being planned 
for the period 10-11 November 1956. Mrs. John Harper and LCDR 
Grace B. Lally (4002 Redden Road, Drexel Hill, Philadelphia, Pa. ) are 
members of a committee to obtain names, addresses, and expressions of 
interest of former officers attached to the Center. 

The Surgeon General has expressed an interest in assisting the com- 
mittee in planning their reunion. 

LCDR Lally will supply interested officers with full details of the 
planned reunion. (National Naval Medical Center) 

^t* ^fi* ^Jfc 

Admiral Burke Heads Navy Mutual Aid Association 

The Board of Directors of the Navy Mutual Aid Association, on 
17 February 1956, announced the election of Admiral Arleigh Burke, USN, 
as President. Other officers elected by the membership were Rear Admiral 
A.H. Van Keuren, USN Ret, First Vice Presidnet, Rear Admiral Frank 
Baldwin, SC USN RET, Second Vice President, and Major General R. E. 
Hogaboom, USMC, Third Vice President. 

Captain T. 5. Dukeshire, SC USN RET, was reelected Secretary and 
Treasurer. All officers and Board members serve without compensation 
with the sole exception of the full time Secretary and Treasurer. 

The Board announced insurance in force in excess of $107,000,000 
and total assets of more than $30,000,000. A total of 2175 new members 
joined the Association during 1955, which made it the most successful year 
in the Association's 77-year history. Some major accomplishments during 
1955 were: new plans of insurance offered (paid-up at ages 50, 55, and whole 



Medical News Letter, Vol. 27, No. 6 



23 



life; increase in terminal dividend from $500 to $1000; age limit raised 
to 62 years; and extension of services to members and dependents. (Navy 
Mutual Aid Association) 

s): * * * * * 

From the Note Book 

1. Dr. Frank B. Berry, Assistant Secretary of Defense (Health and 
Medical), recently, in a memorandum to the Secretary of the Navy, com- 
mended the Navy Medical Department, the Oakland Naval Hospital, Captain 
T. J. Canty, MC USN, and Lieut. C.C. Asbelle, MSG USNR, (Inactive) 
for their extraordinarily fine presentation and participation in the program 
of the Congress of the Latin American Society on Orthopedics and Trauma, 
in Mexico City. Rear Admiral B. W. Hogan, MC USN, Surgeon General 

of the Navy, conveyed his personal congratulations to Dr. Canty, Lieut. Asbelle, 
and the Commanding Officer of the Naval Hospital, Oakland, as well as an 
official commendation to them for a job well done. (TIO, BuMed) 

2. The Advisory Medical Board of the Leonard Wood Memorial for the 
Eradication of Leprosy (American Leprosy Foundation), elected Dr. Howard 
T. Karsner as its Chairman on February 25, 1956. Dr. Karsner, Medical 
Research Advisor to the Surgeon General of the Navy, has been identified 
with work of the Memorial for nearly 20 years. (TIO, BuMed) 

3. Captain W. M. Silliphant, MC USN, Director of the Armed Forces 
Institute of Pathology, has been appointed a member of the Board of Editors 
of the American Journal of Clinical Pathology. The Journal is the official 
publication of the American Society of Clinical Pathologists. (TIO, BuMed) 

4. The dependent medical care bill has been approved by the House Armed 
Services Committee and sent to the full House for consideration. {TIO, BuMed) 

5. On February 17, 1956, the Secretary of the Navy ordered modification 
of the mission of the U. S. Naval Hospital at Mare Island, Calif. The Hospital 
will now provide limited general clinical and hospitalization services for 
shore activities and fleet units present in the Mare Island Shipyard. General 
clinical and hospitalization services in a limited degree will also be provided 
for dependents of the Armed Forces and other authorized supernumeraries 

in the vicinity of the Naval Shipyard. The new operating bed capacity of the 
Mare Island Naval Hospital has been set at 50 beds. (TIO, BuMed) 

6. The Naval Dental School, National Naval Medical Center, conducted 
a special training course in Use of the Manikin and Other Spec ial Training 
Aids for Teaching Casualty Treatment for Army and Air Force personnel, 
February 15 through 17, 1956. (TIO, BuMed) 



24 



Medical News Letter, Vol, 27, No. 6 



7. Commander J. L. McCartney, MC USNR (Ret), of Garden City, N. Y. , 
has just published his third book. In his present book. Understanding 
Human Behavior, Dr. McCartney discusses the foundations of personality 
and the numerous techniques used by psychiatrists to diagnose and treat 
maladjusted individuals. 

8. Lantern slide sets on Tumor Pathology are available on a loan basis 
fr om the Armed Porces Institute of Pathology. These are reproductions 
of the illustrations published in the various fascicles of the Atlas of Tumor 
Pathology. A listing of the available sets as well as a loan request form 
may be obtained from the Director, Armed Forces Institute of Pathology, 
Washington 25, D. C. (AFIP) 

9. Doctors from all over the United States have been invited to attend 
an Armed Forces Institute of Pathology postgraduate course on diseases 
of the heart to be held in Washington, D. C. , May 14 - 17, dealing with 
heart diseases from various clinical aspects as well as the pathologic view- 
point. This is another service of AFIP, the central laboratory of pathology 
for the Armed Forces. (AFIP) 

10. The accidental exposure of a group of Marshallese and Americans to 
radioactive fallout in 1954 necessitated organizing and equipping an emer- 
gency medical team to conduct essential laboratory and clinical examina- 
tions of the exposed individuals. This report j.s concerned with the material, 
facilities, and personnel required for emergency laboratory analyses. 

(NM 006 012. 04. 91, NMRI, November 18, 1955) 

11. During 7-1/2 years' operation of the Cancer Detection Center at the 
University of Minnesota, 173 cases of cancer were found during a total of 
19,890 examinations performed on 7375 people. This represents one cancer 
for every 42 people examined (2. 3%), and one cancer for every 115 exam - 
inations performed. (Surgery, January 1956; C. R. Hitchcock, M. D 

W. A.- Sullivan, M. D. ) 

12. A study of 237 pregnancies in women 44 years of age and over is taken 
from 71,827 pregnancies over a 20 year period. The incidence of pregnancy 
and the incidence of abortion are shown. The age distribution and outcome 
of the pregnancy are presented. (Am. J. Obst. & Gynec, February 1956- 
E. F. Sta|iton, M. D. ) 



13, This article reviews experience with acute intussusception and evaluat 
results with the nonoperative form of therapy for this condition. (Ann. Surg 
January 1956; T. V. Santulli, M, D. , J. M . Ferrer Jr. , M. D. ) 



es 



Medical News Letter, Vol. 27, No. 6 



25 



14. The results of a study indicate that Malathion and Chlorthion can be 
safely used in aerosol form against adult mosquitoes in populated areas. 
(American Industrial Health, January 1956; D. Culver, M. D. , P. Caplan, 
B.S., G.S, Batchelor, M.S.) 

15. The 19th case of primary rhabdomyosarcoma of the heart with autopsy 
findings is reported in J. Pediat. , February 1956; G. Manson, M. D. , 

W. Rindskopf, M. D. 

16. The clinical, radiologic, and pathologic aspects of 23 reported cases 
of pulmonary intracavitary fungous ball are reviewed and the details of 4 
new cases presented. (Radiology, January 1956; E. J. Levin, M. D. ) 

17. Cardiac and intrathoracic vascular surgery has arrived at the point 
where certain established operations may be safely carried out by the 
general thoracic surgeon in a non-university hospital. The medical respon- 
sibility for the proper handling of such operations is shared equally by 
internist, surgeon, and anesthesiologist. (Dis. Chest, February 1956; 
D.J. Dugan, M. D. , J. F. Sadusk, Jr., M. D. , P. C. Samson, M. D. ) 

!{e * * * * * 

BUMED NOTICE 6320 3 February 1956 

From: Chief, Bureau of Medicine and Surgery 

To: All Activities Having Station Hospitals or Dispensaries 

Subj: Professional care of patients 

This notice encourages medical officers in addressee activities to seek 
early consultation in cases where major difficulties might be encountered. 

' * * * * * 

BUMED INSTRUCTION 1520.8 6 February 1956 

From; Chief, Bureau of Medicine and Surgery 

To: Ships and Stations Having Officers of the Medical Corps Regularly 
Assigned 

Subj: Short postgraduate courses for medical officers; guidelines for 
Bureau defrayment of travel and per diem expenses 

This instruction provides guidelines for attendance at short postgraduate 
courses. BuMed Notice 1520 of 1 5 December 1955 is canceled. 



26 



Medical News Letter, Vol. 27, No. 6 



BUMED NOTICE 6700 10 February 1956 

From: Chief, Bureau of Medicine and Surgery 

To: All Stati ons Having Medical Personnel Regularly Assigned 

Subj: Emergency aspirator for ambulances; Beneficial Suggestion 

No. 416 from the National Naval Medical Center, Bethesda, Md. 

End: (1) Diagram of emergency aspirator for ambulances 

The purpose of this notice is to provide addressees with information on 
subject beneficial suggestion. 

BUMED INSTRUCTION 6710.27 15 February 1956 

From: Chief, Bureau of Medicine and Surgery 
To: All Ships and Stations 

Subj: Defective medical and dental material; authority for disposition of 

Ref; (a) Medical and Dental Materiel Bulletin, Edition No, 63 of 
1 Feb 1956 
(b) Art 25-21 ManMed 

This instruction provides authority for disposal of defective material 
listed in paragraph IV of reference (a). 

****** 

BUMED NOTICE 6710 17 February 1956 

Chief, Bureau of Medicine and Surgery 

All Ships and Stations Having Medical Department Personnel 
Assigned 

Subj: FSN 6505-149-1720 Water for Injection, USP, 1000 cc. 6's; 
precautions concerning 

This notice directs the attention of all Medical Department personnel to 
certain hazards inherent in the labeling of subject item. 



From : 
To: 



****** 



Medical News Letter, Vol. Z7, No. 6 



27 



BUMED NOTICE 6710 



23 February 1956 



From: Chief, Bureau of Medicine and Surgery 
To: All Ships and Stations Having Medical/Dental Personnel 
Regularly Assigned 

Subj: Antibiotics; extension of potency dates 

Ref: (a) Medical and Dental Materiel Bulletin (MDMB) Editions No. 6l 
of 1 Dec 1955, No. 62 of 1 Jan 1956, and No. 63 of 1 Feb 1956 

This notice provides authority to extend the potency dates of certain antibiotics 

BUMED INSTRUCTION 12250. lA 27 February 1956 

From: Chief, Bureau of Medicine and Surgery 

To: Activities Under the Management Control of BuMed 

Subj: Ungraded position ratings; current maintenance review of 

Ref: (a) NCPI 250. 3-6 

(b) NCPI 250. 3-7 

(c) NCPI 250. 3-8 

This instruction provides instructions supplemental to NCPI 250 concerning 
the annual maintenance review of ungraded positions and secures necessary 
reports of accomplishments. BuMed Instruction 12250. 1 of 2 February 1953 
is canceled. 



From: Chief, Bureau of Medicine and Surgery 

To: Ships and Stations Having Medical /Dental Personnel Regularly 
Assigned 

Subj: Nonstatic blankets; use of in areas employing oxygen or anesthetics 
This instruction advises addressees of the availability of nonstatic cotton 



sic ij: :{( 4: 



BUMED INSTRUCTION 5101. 2 



28 February 1956 



blankets. 



9{C ^ i!^ 3(c 



28 



Medical News Letter, Vol. 27, No. 6 



DEIMTAl 




Plane Crashes and Dental Records 



The recent story of the Marine Corps plane that crashed in Califor- 
nia in which the manifest listed the names of passengers who were actually 
on another plane, highlights a little known, but important, function of the 
dental officers on duty at the Dental Division and the importance of accurate 
dental records in identification of the dead. 

When the list of the names aboard the ill-fated plane reached the 
Bureau of Medicine and Surgery late on the night of the 17th of February 
1956, the BuMed duty officer called the Dental Division duty officer. Captain 
E. E. Jeansonne, DC USN, and made arrangements to obtain the dental records 
from the Physical Qualifications and Medical Records Division. When the 
records were obtained. Captain Jeansonne, assisted by Captain R.D. Wyckoff, 
DC USN, began their examination of the dental records of those reported 
aboard the plane. The transfer of the data on the dental records from Wash- 
ington to California, so that positive identification could be made, was accom- 
plished by telephone between BuMed dental officers and the dental duty officer 
of the U.S. Naval Hospital, Oakland, Calif. , Commander W.A. Nelson, 
DC USN. It is interesting to note that the transfer of the dental markings 
on the records took only an average of about two minutes per person. This 
is remarkable when the number of dental markings on the chart of the average 
person is considered and, also, that a translation of markings and tooth num- 
bering had to be made in some cases because of the differences between old 
and new type dental records. Altogether, the three dental officers involved 
worked through the night in this effort of positive identification which is so 
important to the next of kin and for the settling of estates. The following 
day, when the error in the passenger listing was discovered, this effort was 
repeated when Captain J, T. Mudler DC USN, who assumed the Dental Division 
duty, examined the new records and transferred the information to Lieutenant 
(JG) J. R. Law, DC USN, on duty at the Oakland Naval Hospital. 

This story should be kept in mind by all dental officers when dental 
records are made. Often, the teeth are the only way by which identification 
can be established. The importance of accurate markings on the dental record 
plus prompt submission of records to the Bureau cannot be overemphasized. 



Medical News Letter, Vol. 27, No. 6 



29 



Naval Reserve Dental Companies 



Listed below are Naval Reserve Dental Companies established in the 
various naval districts that are composed entirely of dental students who 
are commisbioned Ensigns (1995): 

Naval Reserve Dental Company 3-10 New York University 

Naval Reserve Dental Company 4-8 Temple University 

Naval Reserve Dental Company 4-9 University of Pennsylvania 

Naval Reserve Dental Company 4-10 University of Pittsburgh 

Naval Reserve Dental Company 4-11 Ohio State University 

Naval Reserve Dental Company 4-12 Western Reserve University 

Naval Reserve Dental Company 5-6 Medical College of Virginia 

Naval Reserve Dental Company 6-12 University of Tennessee 

Naval Reserve Dental Company 6-13 Emory University 

Naval Reserve Dental Company 8-4 Loyola University (New Orleans) 

Naval Reserve Dental Company 11-2 University of Southern California 

Naval Reserve Dental Company W-2 Georgetown University 

Listed below are Naval Reserve Dental Companies established in naval 
districts having Ensigns (1995) on roster: 



Naval Reserve Dental Company 3-2 
Naval Reserve Dental Company 9-6 
Naval Reserve Dental Company 9-9 
Naval Reserve Dental Company 9-11 
Naval Reserve Dental Company 12-1 



New York City, N. Y. 

Evanston, 111. 

Iowa City, Iowa 

St, Louis Mo. 

San Francisco, Calif. 



Naval Reserve Dental Company 12 -12 Oakland, Calif. 



)(; 9jc 3): !{: ^ ift: 



Med ical and Dental Professional and Technical Books - 

Procurement of 

The attention of dental activities is directed to BuMed Instruction 
6820. 4C of 10 February 1956. The purpose of this instruction is to inform 
addressees of the procedure to be followed in the procurement of professional 
and technical medical and dental books. BuMed Instruction 6820. 4B is super- 
seded and canceled by this instruction, 

9^ « iJC 3|C # « 



30 



Medical News Letter, Vol. 27, No, 6 
Procurement for Ensigns (1995) from Class of 1959 



A Naval Recruiting Note was sent out from BuPers to all offices 
of Naval Officer Procurement on February 17, 1956, directing them not 
to accept any more applications from dental students in the freshman 
class for this program after that date. After applications now received 
from this class are processed, there may be some vacancies, and if so, 
procurement will be reopened on a quota basis. This program was closed 
to members of the sophomore, junior, and senior classes by earlier action. 

First Naval District Medico-Dental Symposium - March 1956 

The First Naval District Medico-Dental Symposium for the Armed 
Forces was conducted at the U. S. Naval Hospital, Chelsea, Mass., March 
21 - 23, 1956. Rear Admiral Ralph W. Malone, DC USN, Assistant Chief 
for Dentistry and Chief, Dental Division, Bureau of Medicine and Surgery, 
and Captain T. DeWitt Allan, DC USN, District Cental Officer, First Naval 
District, participated in the program. 

Establishment of Naval Dental Clinic in Philadelphia 

SecNav Notice 5450 of 15 February 1956, establishes the U.S. Naval 
Dental Clinic, U.S. Naval Base, Philadelphia, Pa., under a commanding 
officer, and as a component of the U.S. Naval Base, Philadelphia. The 
Clinic is under the management control of the Bureau of Medicine and 
Surgery and under the military command of Commander, U. S. Naval Base, 
Philadelphia, 

sfi! sjc ' 9jc !^ 3jc 



MEDICM RESERVE SECTION 



New Application Forms for Correspondence Courses 

The enrollment in Naval Correspondence Courses has swelled to such 
a number that procedures for processing applications must necessarily be 
geared to volume handling. To this end, the application forms requesting 




Medical News Letter, Vol. 27, No. 6 



31 



enrollment in officer and enlisted courses have been revised to simplify 
enrollment at the Naval Correspondence Course Center, Brooklyn, New 
York, and the Naval Medical School, Bethesda, Md. When applying for 
correspondence courses. Medical Department Reservists are requested 
to use only the following forms: 

Officer Courses: Application for Enrollment in Officer Corres- 
^ pondence Course, NavPers 992 (Revised 10/54) 

or, forthcoming forms with revisi-on date later 
than 10/54. 

Enlisted Courses: Application for Enrollment in Enlisted Corres- 
~~ pondence Course, NavPers 580. 

All Naval activities have been directed to discontinue use of, and 
destroy all stocks of, the following application forms; Form 992 with 
revision dates of 10 46, 4-47, 12 49, 9-50. and 9-51, and Form Nav- 
Pers 977. 

Stocks of NavPers 580 and NavPers 992 (Rev 10/54) may be requi- 
sitioned from the District Publications and Printing Offices. 

(BuPers Notice 5213 dated 31 Jan 1956) 



****** 
Special Clinical Services - Blood 

The correspondence course. Special Clinical Services (Blood), Nav- 
Pers 10998, was made available to regular and Reserve personnel of the 
Armed Forces Medical Departments in July 1954. This course has received 
high praise from those who have taken it. Among these are physicians who 
are directors of blood banks, chairmen of special committees on blood trans- 
fusions, members of the American Board of Internal Medicine, and the 
Society of the Study of Blood. 

The object of the course is to acquaint Medical Department personnel 
with the basic principles and techniques involved in the preparation and 
administration of blood and blood substitutes, the collection and storage of 
blood, the preparation of plasma, and laboratory procedures including blood 
grouping and crossmatching. This course, while increasing the enrollee's 
knowledge of the field of blood transfusion, also provides an incentive to 
further study and research, and provides background information for students 
preparing for residencies- or for postgraduate work. It may also serve as a 
guide to physicians and technicians in operating blood and plasma banks and 
in organizing and operating transfusion services. 

Since the beginning of World War II, the therapeutic use of blood and 
its derivatives has greatly increased. Research and technical developments 



32 



Medical News Letter, Vol. 27, No. 6 



leading to the successful establishment of blood banks have made it possible 
for hospitals and medical centers throughout the world to process, ship, and 
store blood and its derivatives for future therapeutic use. The consequent 
availability of blood to the doctor and surgeon has led to broad changes in 
medical and surgical practice. The percentage of beneficial results from 
the use of blood in cases of congenital and acquired anemias has risen 
markedly. Many doubtful cases have been re evaluated as excellent pros- 
pects after a course of transfusions and subsequently have been cured by 
surgery. Literally hundreds of lives have been saved by prompt replace- 
ment transfusions in cases of hemolytic disease of the newborn. Likewise, 
the mortality in cases of trauma, shock, and routine surgery has been greatly 
reduced. Mortality in combat casualties has been reduced by more than 50% 
through the therapeutic use of plasma by physicians and hospital corpsmen. 

Two textbooks are required to complete this course: Blood T ransfusion 
by DeGowin, Hardin, and Alsever covers the whole field of blood transfusion 
The other text, Special Clinical Services (Blood ). NavPers 10866 prepared 
by the Bureau of Medicine and Surgery, is a brief but comprehensive descrip- 
tion of the clinical use of blood and the techniques involved in the procedures 
necessary for its use. All text material is supplied to enrollees. 

Eligible officers and enlisted personnel, regular and Reserve, of the 
Medical Department may enroll in this course. Applications should be sub- 
mitted on Form NavPer. 992 (with appropriate change in the "To" line) and 
forwarded via appropriate channels to the Commanding Officer, U S Naval 
Medical School, National Naval Medical Center, Bethesda 14, Md. 

This course consists of eight (8) assignments of the objective question 
type and is evaluated at twenty-four (24) Naval Reserve Promotion and Non- 
disability Retirenrient points . Completion of this course provides Naval 
Reserve officers with an additional means of earning non- disability retire- 
ment and promotion point credit, and regular Navy personnel with an alter- 
nate method by which they may, in part, qualify for promotion. 

( * * * 3jc sj: :{! 

New England Hospital Assembly Approved for Point Credits 

The New England Hospital Assembly sessions, 26, 27, and 28 March 
1956. at Boston, Mass. , will mark its 35th anniversary year. Founded 
in 1921 as the New England Hospital Association, the NEHA was the first 
regional hospital organization in the United States. 

Each year attendance at the annual assembly has grown. Last year 
nearly 6000 attended the three -day meetings. Expectations are that the 
1956 sessions will see this attendance record broken. 

There will be three sections in the 1956 Assembly: General Sessions, 
Instructional Conferences, and Section Meetings. Top -flight speakers and ' 
discussants in all sessions are expected to attract capacity audiences. 



Medical News Letter, Vol. 27, No. 6 



33 



Eligible inactive Reserve Medical Department officers who attend 
will earn retirement point credits provided they register daily with the 
military representative at the Assembly who is authorized to record such 
attendance. Appropriate duty orders are not required. 

The complete program and full information may be secured by writing 
to the District Medical Officer, First Naval District, 495 Summer Street, 



Boston 10, Mass. 

jj: jj: * * * 



^^^^^ PREVENTIVE MEDICINE SECTION' 




The Otologist's Role in an Industrial Hearing 
Conservation Program 

An industrial hearing conservation program, to be successful, re- 
quires the cooperation of management, workers, and health and safety 
personnel. The otologist who interests himself in the many facets of occupa- 
tional hearing loss can play a key role. 

Each plant has an individual noise problem and the program should be 
tailored to the needs of the particular plant. It should not be too costly nor 
require the worker to be absent from work too long. A suitable room and 
a pure tone audiometer are required for testing. Speech reception, discrim- 
ination tests, and bone -conducting thresholds require optimum testing con- 
ditions. These tests should be performed in the otologist's office. The 
plant hearing tests may be performed by trained and interested personnel 
of the plant. Interpretation of audiograms should be done by the medical 
man. 

If significant hearing loss is detected at the time of hiring, the worker 
must be carefully examined and placed after thorough hearing studies. Careful 
distinction between conductive, perceptive, and mixed types of hearing loss 
is important in placing workers. The otologist also must detect wilful ex- 
aggeration of either hearing ability or hearing loss by workers. 

The otologist also participates in the medicolegal aspects of hearing 
claims. The status of the employee's hearing at time of hiring is of critical 



34 



Medical News Letter, Vol. 27, No. 6 



importance in cases of claim for hearing loss. Employers should require 
routine audiom etric tests as part of pre-employment physical examinations. 
The choice of formula for evaluating hearing test results in terms of percen- 
tage of hearing disability is controversial. The problem of permanency of 
hearing loss is difficult to solve. Appropriate allowances should be made 
for hearing loss which can be expected in normal aging. 

A hearing conservation program begins with a thorough study of noise 
levels found in various working areas. Areas which reveal sound levels, that 
are potentially damaging, are studied in more detail to determine intensity, 
duration, and frequency characteristics of the over all sound pattern. The 
otologist's contribution to such a program can be judged by the extent to 
which he helps to achieve the following three major objectives: (1) to conserve 
the hearing of the workers; (2) to avoid unnecessary economic loss to the 
employer; (3) to collect data which will enlarge the knowledge of the defects 
of industrial noise and how they can be overcome. {V. Lindsay, 1954-1955 
Series: Year Book of Eye, Ear, Nose and Throat; Fox, M.S. , Otologist's 
Role in Industrial Hearing Conservation Program : Laryngoscope, 64: 79-88, 
February 1954) 

****** 
Foodborne Disease Outbreaks 



Although foodborne disease outbreaks have diminished in the past 
several years, enough cases are still being reported to cause concern. For 
instance, over 3000 Naval and Marine Corps personnel were treated during 
the calendar year 1955 for diseases caused or suspected of being caused by 
contaminated food. It is easy to understand why more emphasis should be 
placed on the prevention of these outbreaks when they are broken down to 
man hour loss. An average of 2 days were lost by each of the 3000 patients 
with reported cases — a total loss of approximately 48,000 man hours. 

The type of food associated with these outbreaks varies considerably. 
Poultry and poultry dishes were connected with approximately 20% of the 
total cases. Other foods in their order of importance include pork products, 
beef products, various salads, puddings, and fresh oysters. It is of interest 
to note also that 29 men were treated for metallic poisoning. These men 
consumed orange juice from a container which, upon being tested, revealed 
the presence of cadmium. 

By far the most common discrepanceis noted in the investigation of 
these outbreaks were the lack of proper supervision and food-service train- 
ing programs. Next in order, were improper refrigeration and unsatisfac- 
tory or inconvenient handwashing facilities. A good example of improper 
supervision over food-service personnel was demonstrated recently aboard 
a ship in the Atlantic fleet. In this instance, two isolated epidemics of 



Medical News Letter, Vol. 27, No. 6 



35 



foodborne illness occurred within 5 days, one involving 15 men and the 
other 25. The first outbreak was caused by contaminated roast pork and 
the second by hot turkey sandwiches. The only common factor involved 
was considered to be a contaminated cutting board. Had proper supervision 
over food-service personnel and adequate food-service training been accom- 
plished, this outbreak might have been avoided. 

The medical officer or Medical Department representative is respon- 
sible for making recommendations necessary to safeguard the health of 
personnel. Sanitary supervision over food-service operations and surveil- 
lance of the daily nutritional adequacy of diets is a very important and exact- 
ing duty which confronts the Navy Medical Department. In addition, the health 
and personal hygiene of all food-service personnel must be considered. 

Medical officers should maintain constant surveillance over food- 
service operations and food-service training, and utilize environmental 
sanitation technicians to the fullest extent possible in conducting and super- 
vising the training program. The following Bureau of Naval Personnel aids, 
developed with the collaboration of the Bureau of Medicine and Surgery and 
the Office of the Surgeon General, U.S. Air Force, will provide an excel- 
lent guide to the instructor in conducting food-service training courses: 

1. NavPers 91921A - Instruction in Sanitary Precautions for 
Food -Service Personnel (1956 Revision). 

2. NavPers 230074 - Flip Charts for Training Food Service 
Personnel, 1956. 

3jC Sjc 9jC !^ 

The TPI Test in the Navy 

The Treponema pallidum Immobilization Test for Syphilis {TPI test) 
measures the presence of the treponemal immobilizing antibodies which, 
according to current evidence, develop only in response to treponemes in 
the body. These antibodies usually develop at some time between the "Early" 
and "Early Latent" stages of syphilis, and, once they have developed, the 
individual's TPI reaction remains positive for life, regardless of future 
treatment. However, if treatment is instituted in the "Early" stage before 
TPI antiboides develop, these antibodies maybe prevented from developing 
and the TPI test from this infection will never become positive. 

Therefore, a positive TPI reaction indicates that the individual most 
probably had a treponematosis at some time in the past, though it may even 
not be indicated by the present or recent signs, symptoms, and standard 
serology. This treponematosis may have been yaws, pinta, or bejel, as 
well as syphilis; however, in an individual who has never left the United 



36 



Medical News Letter, Vol. 27, No. 6 



States, syphilis is most probably the cause of the positive TPI test. Bejel 
would be considered strongly only in one who had lived among the Arab 
nations, and pinta could be considered a possibility in Negroes and Indians 
who had lived in Central America, South America, or the tropics. 

When standard serological tests are negative and the TPI positive, 
the patient usually has treated late syphilis or one of the other treponemal 
infections . 

When negative results are obtained to both the standard serologic test 
and the TPI test, two possibilities are present, namely: (!) that the individ- 
ual has never had syphilis, or (2) that, if the individual has had syphilis, the 
disease was treated in its very early stages so that the TPI antibodies never 
developed. 

When the standard serological tests are positive and the TPI negative, 
the patient is usually a biologic false positive reactor; rarely, he may have 
had treated early syphilis. The frequency of the occurrence is illustrated 
by the fact that within the past 6 months 90 instances of biologic false pos- 
itive reaction were revealed by the TPI tests performed at the Naval Medical 
School, 

A repeated positive TPI test is more specific evidence of treponemal 
infection than a repeated positive standard serologic test. 

The Sixth Army Medical Laboratory, Fort Baker, Calif. , performs 
the TPI tests requested by the Pacific Fleet and by the Naval Forces in the 
Far East, the Philippines, the Marianas, the Territory of Hawaii, Alaska, 
and the States of California, Oregon, and Washington. The TPI Laboratory, 
Naval Medical School, National Naval Medical Center, Bethesda 14, Md. , 
performs the TPI test for all other naval activities. NavMed Form -1351 
has been used to request this test ; however, as soon as present supplies are 
exhausted, the new DD Form -876 will be used by the Navy, as well as the 
other branches of the Armed Forces, 

When all the following conditions exist, a .l PI test should be performed 
before a diagnosis of syphilis is established : (1) Two standard serologic 
tests on blood drawn 5 to 7 days or more apart are doubtful or positive; 
(2) There is no history of previous diagnosis for syphilis; and (3) There are 
no current signs or symptoms of primary or secondary syphilis, and there 
is no definite clinical evidence of late syphilis in any form. 

The results of each TPI test shall be entered in the i ndividual's health 
rec ord on Standar d Form-602. ~ ' ~ 

The TPI test has proved to be a new invaluable aid to the clinician in 
both diagnosing and excluding the diagnosis of syphilis. The occurrence of 
false positive standard serological tests has already been mentioned, but 
it is again emphasized that it is also possible for a patient to have false 
negative STS reactions as the reagin titre falls to levels that cannot be de- 
tected following treatment, whereas the immobilizing antibody of the TPI 
remains at a high titre for life. 



Medical News Letter. Vol. 27, No. 6 



37 



American Academy of Occupational Medic ine - 
Notes on Annual Meet ing 

The American Academy of Occupational Medicine held its Eighth 
Annual Meeting, celebrating the Tenth Anni versary (1946 - 1956) of the 
founding of the Academy at the Netherland Plaza Hotel's Pavillion Caprice 
in Cincinnati, Ohio, February 15, 16, and 17, 1956. Honors were given 
to charter members with special tribute to Doctor George H. Gehrmann, 
one of the founders and the first President, 

The scientific sessions consisted of a review of the organ systems 
by specialists in each field. Discussions were presented concerning the 
signs and symptoms that are the result of influences in the working environ- 
ment. Particular attention was given to the findings that are indicative of 
occupational diseases. Special considerations on history of exposure and 
effective dose were included in the presentations. The skin, respiratory, 
circulatory, hemopoietic, liver, gastrointestinal, genito -urinary, and 
central nervous systems were reviewed. 

Routine programs of investigation were described as well as special 
services that are available to industry from private laboratories, local and 
- state health departments, and Federal agencies. An afternoon was set aside 
for field trips to the Robert A. Taft Sanitary Engineering Center, the Occu- 
pational Health Field Headquarters of the Department of Health, Education, 
and Welfare, Public Health Service, and the Kettering Laboratory, Univer- 
sity of Cincinnati Medical School. 

The Academy's Annual Dinner and the First George H. Gehrmann 
Lecture were held in the ballroom of the Cincinnati Club. Following the 
dinner. Doctor Frank Princi, President of the American Academy of Occu- 
pational Medicine, introduced the speaker, Mr. Emile F. DuPont, Director, 
E, I. DuPont de Nemours and Company, Incorporated, Wilmington, Del. 
Mr. DuPont traced the development and history of the occupational health 
program in his company over the past 40 years. He paid high tribute to 
Doctor Gehrmann who served with the company during that period. 

Following Mr. DuPont's address. Doctor Gehrmann made a few remarks 
expressing deep gratitude for the honors bestowed upon him. He called atten- 
tion to others such as Doctor Robert A. Kehoe and Doctor James H. Sterner 
who have worked hard over many years in raising the standards of occupa- 
tional medical practices. 

The final scientific sessions on the last day of the meeting covered 
the clinical effects associated with heliarc welding, the diagnosis and 
treatment of back pain and evaluation of ability to work, and the treatment 
of methemoglobinemia. 



« ijc * 4 * ](: 



38 Medical News Letter, Vol. 27, No. 6 

Progress Report on the Manual of Naval Preventive Medicine - 

NavMed P-5010 

Chapter 1, Food-Service Principles, has been cleared and forwarded 
to the Government Printing Office for publication. It is anticipated that 
Chapter 1 will be distributed to the field some time in April. 

Chapter 2, Sanitation of Living Spaces and Related Services , is being 
circulated to interested divisions of the Bureau of Medicine and Surgery 
and to other bureaus and offices and will be returned to this Bureau by 
March 20. This chapter should be completed and sent to the Publications 
Division, Bureau of Medicine and Surgery, for possible distribution in 
May. 

Chapter 3, Ventilation and Thermal Stress Ashore and Afloat , has 
been cleared through all bureaus with major changes recommended. Con- 
sequently, distribution of this chapter will be delayed probably until July 
or August. 

A draft of Chapter 4, Swimming Pools and Bathing Places, has been 
cleared and distribution in early May is in prospect. 

A draft of Chapter 5, Water Supply Ashore, has been completed and 
is ready for reproduction prior to clearance through interested bureaus. 
The anticipated distribution date of this chapter is early August. 

Chapter 6, Water Supply Afloat, is in the process of being written 
and requires additional information on the problem areas prior to com- 
pletion. No distribution date for this chapter is in sight at this time. 

Chapter 7, Sewage Disposal, is in the process of reproduction and 
should be sent out for review and comments with the suggested return date 
of 1 May. Distribution of this chapter in early August is anticipated. 

Chapter 8, Refuse Disposal, requires extensive work for completion. 
Clearance is anticipated by 1 August with distribution in September or 
October . 

Data and information are being assembled for the rough manuscript 
of Chapter 9, Insect and Vector Control . Distribution of this chapter late 
in 1956 is in prospect. 

Chapter 10, Insectici des and Dispersal Methods, was distributed in 
1953. A reprint of this chapter has been requested and is available upon 
request to the appropriate District Publication and Printing Office. 

The title for Chapter 1 1 has not been definitely established, but 
Medical Statistics is being considered. 

A draft of Chapter 12, Field and Emergency Sanitation , is in the 
process of clearance through other bureaus. It is anticipated that, if major 
changes are not recommended, this chapter will be distributed by August. 

Additional chapters are contemplated on Communicable Disease 
Control and Immunization and Occupational Health . 

When Chapter 1 is distributed, information will be published on 
procedures for requesting chapters by interested individuals. The planned 



Medical News Letter, Vol. 27, No. 6 



39 



distribution for each chapter has been to all ships and stations with a 
Medical Department representative. Any information or inquiries regard- 
ing the Manual of Naval Preventive Medicine should be directed to the Chief 
of the Bureau of Medicine and Surgery, Attention: Code 72. 

9^: >!: ^ ^ 

Industrial Health and Accidents in Englan d 

The following item, which appeared in the April 9, 1955 issue of the 
Journal of the American Medical Association, should be of interest to naval 
industrial medical personnel as it shows the similarity between industrial 
health and accident problems in England and problems in U. S. Navy indus- 
trial activities. 

"The Chief Inspector of Factories reports that the number of acci- 
dents in industry in 1954 shows an increase over that in 1953. The number 
of fatal accidents, however, fell from 796 in 1953 to 744 in 1954. Several 
factors contributed to the rise in the number of accidents, such as the 
increased number of man hours worked and the increase in mechanical 
processes undertaken by women workers. The Chief Inspector is con- 
cerned over the increased number of accidents to young people. Lack of 
proper instructions is the greatest cause of machine accidents, although 
employees must share the blame with employers. Better discipline and 
closer supervision would prevent those avoidable tragedies that result 
from youthful high spirits. Referring to ocular injuries, attention is 
drawn to the difficulty of getting workers to use protective devices, 
whether required or not by law. The attitude of management is impor- 
tant. They must treat the matter with the utmost seriousness and this 
attitude must be passed on to employees. The law states that employers 
not only must take all precautions and provide protection against accidents, 
but also must exert all due diligence to see that precautions and protection 
are employed. Some factories stamp job cards with appropriate reminders 
and others have used intensive propaganda campaigns. More rigorous 
legislation is needed to prevent ocular injuries whichnumbered 7738 in 1954. 
Although, in many factories first aid equipment is in excess of that re- 
quired by law, in too many others the equipment consists of small tin 
boxes covered with rust and dirt, containing a few grimy remnants. 
Similarly, the standard of first-aid attendants varies widely. All factories 
employing more than 50 workers are required to have personnel trained in 
first aid, but the training is not defined. Factory inspectors have increas- 
ing difficulty in getting volunteers for first-aid duties even when there is 
monetary inducement, and factory managements have been warned of the 
importance of first aid. 



40 



Medical News Letter, Vol. 27, No. 6 



The report also draws attention to the difficulty of persuading 
employers and workers of the necessity of a high standard of cleanliness, 
even when the trade is a 'dirty' one. Too often, dirt and rubbish are 
allowed to accumulate and are cleaned up only periodically. As a rule, 
larger factories are cleaner and better maintained than smaller ones, 
and some of the cleanest factories are those in which the work is 'dirtiest. 
More and more factories are installing modern systems of heating, but 
in many, lighting and heating methods are still obsolete. In designing 
new factory buildings, more consideration should be given to ventilation 
and heating. Health is not merely a matter of protection against injury 
and disease. The worker should not be looked on as a unit or clock 
number, but as a human being, and there is evidence that factory man- 
agements are aware of the need for promoting mental as well as physical 
health in their employees. " 



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